Case of the Week # 276

Irina Tihonenko, MD.*, N. Venchikova, MD.**, A. Nerovnya, MD.***, O. Yushchenko, MD.****

September 9, 2010 - September 23, 2010.

*    Minsk Prenatal Ultrasound Center, 1st Minsk Clinic Hospital, Minsk, Belarus.
**   Republic Center "Mother and Child", Belarus.
***  Chair of the Department of human pathology, Belarussian Medical State University, Belarus.
**** Minsk Department of human pathology, Belarus.

Case report

This is a case of a 36-year-old healthy G2 P0 who was referred to our department for the ultrasound scan at 34 weeks of gestation. Personal and family history were both non-contributive. Patient did not have any history of a drug abuse. 
The first trimester scan and biochemistry were normal.

The ultrasound examination revealed the following findings.

Images 1-6: 34 weeks.

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Images 7,8: Doppler imaging, 34 weeks.

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Images 9 -12: 34 weeks.

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Answer

Case report

This is a case of a 36-year-old healthy G2P0 who was referred to our department for the ultrasound scan at 34 weeks of gestation. Personal and family history were both non-contributive. Patient did not have any history of a drug abuse.

The first trimester scan and biochemistry were normal.

There was an intraabdominal heterogeneous mass revealed on the ultrasound at 28 weeks of gestation. It was considered to be an abdominal cyst.

Patient had a follow-up ultrasound examination at 33 weeks of pregnancy. There was a large heterogeneous mass in the abdomen. Mass caused the urinary tract obstruction. Decreased amount of the amniotic fluid was also detected.

During the ultrasound examination at 34 weeks of gestation we found the following:

  • Large intraabdominal heterogeneous solid mass measuring 80x84x72 mm
  • Vascularized mass contained cystic components and calcifications and was of irregular contours
  • Solid pelvic mass of similar apperance measuring 33x29x34 mm, located close to the coccyx
  • Ascites
  • Pyelectasis
  • Cardiomegaly
  • Enlarged placenta
  • Enlarged amount of the amniotic fluid

Our diagnosis based on the ultrasound findings was Sacrococcygeal teratoma, Type IV.

Pregnancy was terminated via cesaren section within two days after our examination due to signs of fetal cardiac failure.  The surgery was performed after delivery and the final diagnosis, based on histopathology examination, was Sacrococcygeal teratoma, Type IV. Urethrovaginal fistula was detected during the surgery. The fistula was probably a way, how did the fetus void later in the pregnancy because the decreased amount of the amniotic fluid at 32 weeks changed into an increased amount at 34 weeks.

Pathology report: Tumor of size 8x7x6 cm, micro: tumor with immature and mature derivates of ecto-, meso- and entoderm. Tumor consisted of immature neuroectoderm with neuroepithelial rosettes and primitive mesenchyma with islands of differentiation towards cartilage with dystrophic calcifications. Mature component was presented by differentiated connective tissue and fat, neuroglia with scanty ganglionic cells, with cysts, lined by respiratory, intestinal epithelium, transitional and laminated cornified epithelium.

Images 1,2: Images show a presacral solid mass which was located close to the coccyx.

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Images 3,4: Image 3 shows a transverse and image 4 sagittal view of the abdomen. Note the large cystic mass.

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Images 5,6: Image 5 show an intraabdominal cystic mass on the sagittal view. Image 6 shows a 3D-image of the cystic mass. 

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Images 7,8: Doppler imaging demonstrates the vascularization of the intraabdominal mass.

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Images 9,10: Image 9 shows mild pyelectasis. Image 10 shows cardiomegaly, sign of heart failure.

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Images 11,12: Image 11 shows enlarged placenta. Image 12 shows both umbilical arteries.

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Images 13,14: Image 13 shows immature neuroectoderm with neurepithelial rosettes. Image 14 shows a mature component, differentiated connective tissue and fat.

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Images 15,16: Primitive mesenchyma with islands of differentiation towards cartilage with dystrophic calcifications.

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Images 17,18: Image 17 shows neuroglia with scanty ganglionic cells. Image 18 shows cyst, lined by respiratory epithelium.

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Images 19,20: Image 19 shows intestinal epithelium. Image 20 shows transitional and laminated cornified epithelium.

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